【作者】 聂斌；

【导师】 杨顺益；

【作者基本信息】 广州中医药大学 ， 针灸推拿学， 2005， 博士

【摘要】 糖尿病(diabetes mellitus,DM)为最常见的内分泌代谢疾病。该病由胰岛素合成与分泌减少,或胰岛素受体及受体后缺陷引起。流行病学研究发现,我国糖尿病的发病率近年呈上升趋势。其不断升高的患病率和广泛的并发症已成为威胁人类健康的重要疾病。近年的研究表明,糖尿病的胃肠并发症颇为多见,尚未有满意的治疗方法。 针灸疗法因其简、便、验、廉在治疗糖尿病胃轻瘫占有一定的优势,能治愈或改善胃轻瘫的症状,同时又能兼顾降血糖,起到双重的作用。为了更系统更全面地探讨电针治疗糖尿病胃轻瘫的临床疗效及作用机制,本文从以下几个方面进行了研究。 一、文献研究 糖尿病胃轻瘫(Diabetic Gastroparesis DGP)是一种常见的、慢性的糖尿病合并症之一。临床上本病的发病率较高,以胃排空延缓为主要病理特征。临床表现除糖尿病原有的症状外,尚兼有上腹不适、早饱、餐后上腹胞胀,甚至恶心、发作性干呕、呕吐等消化道症状。它的发生不仅可明显影响病人食物的消化和吸收,导致消化道症状,还因影响口服药物的吸收而给糖尿病的治疗带来极大的干扰,影响血糖的控制而使糖尿病患者继发严重的代谢失常和心、脑、肾等重要器官的损害。糖尿病胃肠运动障碍的发病机理可能是自主神经功能障碍、胃肠激素分泌异常、高血糖、平滑肌损害以及微血管病变等因素的综合影响的结果。另外,Cajal间质细胞(interstitial cells of Cajal,ICC)损伤或功能失调也可能是糖尿病胃肠动力障碍发生的机制之一。 中医文献中无糖尿病胃轻瘫的病名,临证多依据其早饱、厌食、嗳气、恶心、呕吐、腹胀的症候归入“呕吐”、“痞满”、“胃胀”、“胃缓”等范畴进行辨证论治。糖尿病与胃轻瘫有着密切的关系。基本病机以消渴病日久阴损耗气,致脾虚不运、升降失司,胃失和降导致气滞、湿浊或食积停滞,此外,气虚常致气滞血瘀,瘀再促虚,恶性循环。因此,糖尿病胃轻瘫属本虚标实之证。运用中医整体观和辨证论治的原则,中药、针灸、中西结合治疗本病,能治愈或改善胃轻瘫的症状,副作用小,同时又能兼顾降血糖,起到双重的作用。 二.临床研究 为了评价电针治疗糖尿病胃轻瘫的临床疗效,观察电针治疗糖尿病胃轻瘫患者30例,并以莫沙比利治疗的30例患者作为随机对照,两组均常规服用西药控制血糖,治疗组用电针,每周5次,治疗3周为一疗程。对照组口服莫沙比利,每服5mg,每日三次,三周为一疗程。1个疗程后,从两组病例的胃轻瘫等临床症状以及痞满证的轻重分级、X线钡透胃固体排空等客观指标进行了多角度的临床对比研究。结果:1更多还原

【Abstract】 Diabetes mellitus(DM) is the commonest endocrinal metabolic disease. This disease is caused by the decrease in the synthesis and excretion of insulin, or the insulinreceptor and post-receptor defects. Epidemiological survey found that the incidence rate of diabetes is showing rising tendency. It is progressively becoming a serious public health problem because of its highly morbidity and extensive complications. The recent researches make it clear that the complications of the stomach and intestines also can be seen commonly, and , the satisfied method of treatment haven’ t been found yet.Acupuncture for Diabetic gastroparesis have some advantages because of convenience, availability, efficient and cheapness, that can cure and improve the symptoms of Diabetic gastroparesis and reduce blood sugar. In order to study the curative effect and the mechanism of Electroacupuncture in treating Diabetic gastroparesis more systematically and comprehensively, the article will study from the following three aspects, literature, clinic and experiment. 1.Literature researchDiabetic gastroparesis(DGP) is a common and chronic complication of diabetes. It has a high incidence rate , and its pathological character mainly refers to delayed gastric emptying. Clinical situation may include the symptoms of diabetes, the symptoms in digestive tract such as epigastric discomfort, early satiety, and postprandial epigastric distention, constipation even nausea, paroxysmal retching, and vomiting etc. It is manifested by not only dyspeptic symptoms, but also the delayed gastric emptying will affect the absorption of oral medicine, that lead to the difficulty of control to blood sugar and metabolic disorder. All of them will do harm to the organ of heart, brain, and kidney. The pathogenesis of the malfunction of stomach dynamic and paresis of diabetes is likely linked withthe pathological changes of autonomic neuropathy, the disturbance of gastrointestinal hormones, hyperglycemia , the impairment of stomach smooth muscle, stomach microvascular pathological changes etc. In addition, the damages or functional disorders of Interstitial Cells of Cajal (ICC) are probably one of the mechanisms of the Diabetic gastroparesis.The literature of traditional Chinese medicine(TCM) had no the name of Diabetic Gastroparesis. According to the main clinical symptom of stuffness, anorexia, belching, vomiting and nausea, abdominal distention etc, Diabetic gastroparesis was discussed by "fullness sensation in the chest and abdomen" , "gastric fullness" , "vomit" , "tardy stomach" in the ancient books and records of Traditional Chinese Medicine. The diabetes mellitus and gastroparesis has close relationship.Its basic pathogenesis is that the long diabetes mellitus result in spoilage of yin and qi, that furthermore lead to spleen-asthenia and malfunction of transportation and transformation, abnormal ascending and descending of the qi, inability of the descending of stomach-qi that causes qi stagnation, damp obstruction or stagnation of food. Besides, qi-deficiency often causes qi-stagnancy and blood stasis. Blood stasis promotes deficiency conversely, which is a vicious cycle. As a result, Diabetic gastroparesis belongs to root-deficient and branch-sufficient syndrome.Under the direction of the principle of the integral view and differentiation of TCM, to treat this disease with the method of Chinese medicine, acupuncture and moxibustion and combination of traditional Chinese medicine and western medicine can cure or relieve the symptoms of stomach paresis, and the side effect is very light, at the same time it can lower blood sugar, and serve a dual purpose.2. Clinical studyA single-blind randomized clinical trial was made for a rough test and verifying. 60 patients with diabetic Diabetic gastroparesis were divided randomly into treatment group (n=30) and control group (n=30). Blood glucose of both groups are under the control of routine western medicine, Treatment group was treated by Electro-acupuncture , 5 times a week, while control group was administered with Mosapride, 5 mg once, three times a day. All patients was treated for 3 weeks, clinical symptoms, "gastric fullness" level, Barium meal examination will be measured before and after treatment, the resultsshowed that (1)In treatment group the total effective rate was 93. 33%, and cure rate was 43. 33%, in control group the total effective rate was 90%, and cure rate was 40%. There was no statistically significant difference between the two groups(p>0. 05). (2)Electro-acupuncture and Mosapride can promote gastric emptying, after treatment has significant difference in comparison with the before treatment (P<0.01), and there was no statistically significant difference between the two groups(p>0.05). (3) The main symptoms and complications of both group were improved greatly after treatment. The efficiency of two group was similar(p>0. 05). (4)To treatment group, the total effective rate and cure rate in the three type have no difference. ?The blood glucose was lowered significantly after treatment(P<0.01). There was no significant difference between the two groups on lowering the blood glucose. The above results demonstrate that Electroacupuncture and Mosapride are similar in curative effect to treat Diabetic gastroparesis. Electro-acupuncture can be regarded as an effective therapy without obvious side-effect for Diabetic gastroparesis. 3. Experimerits study60 SD common class male rats were chose as experimental rats , after they was measured blood sugar and urine glucose, we chose randomly 42 rats to make diabetic mellitus model. Those rats was injected streptozotocin (STZ)(0.1mol/L), which was made up freshly by sodium citric buffer ,into their’ s abdominal cavities with a 60 mg/kg dosage one time .The rest 18 rats were taken as control group. Rats made DM model successfully were divided randomly into two groups including diabetic model group (abbr. DM), diabetic model group treated by Electroacupuncture group (abbr. DM+ACU)which were treated by Electroacupuncture after 10 week, one time per day, 5 days for one couse of treatment, rest 2 days between two course, lasted 4 courses. During the experiment, the rats’ common condition, such as appetite, the volume of urine and excrement, activity, weight, blood glucose were observed and noted on schedule. After test weight, blood glucose the day before the last day, Fasting 24h after the last feeding, each group fed carbo-powde suspension by orally taking (activated carbon and acacia each contains 10%), lOml/kg. put rats to death by stretching their’ s collum after 30 minutes. Calculating the stomach-intestine driving marker. The gastric antrum was divided into three parts. One is to make HE Staining and immunohistochemistry of c-kit mark, onepart for examining gene express of c-kit by fluorescent quantitative polymerase chain reaction(FQ-PCR).Other gastric antrum tissues is to make samples for the observation by transmission electron microscope, the results showed that(1)The rats of the DM group and the DM+ACU group compared with the control group, blood sugar significantly increased(P<0.01). The DM+ACU group rats’ blood sugar were lower than that of DM group, but there is no difference between them, it state that Electroacupuncture can drop blood sugar, but no effective to treat Diabetes mellitus. (2)The rats of the DM group and the DM+ACU group compared with the control group, gastric emptying significantly decreased(P<0. 01). The DM+ACU group rats’ gastric emptying were much more than that of DM group(P<0.01). It state that Rats made DM model were successful;Electroacupuncture can promote gastric emptying. (3) Under observation of optic microscope and electronic microscope, we found that the arrangement of smooth muscle cells in control group rats is in good order, the distance among cells is moderate, and there are plenty of organelles in muscle cells. The cell nucleus in intermuscular plexus is clear, having plenty of organelles and great deal of mitochondria and rough endoplasmic reticulum. The electron density is well-distributed in neuraxon and neurodendron end-brushes, and there are many synaptic vesicles inside neurotic varicosities. Neighboring to intramuscular neurons, The ICC can be seen, its cells contain plentiful mitochondria, endoplasmic reticulum, well developed Golgi apparatus, intramembrane caveolae, vacuoles, and abundant ribosomes. The cell protuberance form incomplete sheath structure surrounding neurotic fasciculus. The inside-wall nerve and ICC protuberances combine mutually and form a nexus, and is well-distributed. This group of rats has smooth capillary dissepiments, and complete endothelial cell. In DM group rats , the arrangement of smooth muscle cell disordered, the distance among cells change wider clearly, there were many vacuolation and lysis in cytoplasm of muscle cells, mitochondria were swellimg, vacuolating and lysing. The nucleus of infra-muscles Plexus Neuron lyse and necrose, and cytoplasm part lysing, mitochondrion swelling, crest lysiing, and rough endoplasmic reticulum expanding.There were swelling, lysis, vacuolation and disequilibrium of electric density in the neuraxon, neurodendron and end-brush.The content of synaptic vesicle in neurotic varicosity notable decreased. And the number of ICC in DM group decreased compared to the control group rats. The ICC is wither and cell project更多还原